The role of exercise in aromatase inhibitor-induced arthralgia.

Aromatase inhibitors are prescribed in breast cancer due to their associated lower rate of cancer recurrence compared to tamoxifen. However, aromatase inhibitor-induced arthralgia (AIIA) is one of the leading causes of treatment nonadherence, increasing the risk of cancer recurrence. The pathophysiology of AIIA is poorly understood, and although current recommendations for AIIA include lifestyle changes and analgesics depending on the severity of symptoms, there is no established effective treatment. The aim of this study is to explore the presentation and mechanism of AIIA and investigate the feasibility and efficacy of different exercise interventions (aerobic, resistance, aerobic and resistance combined, and yoga or tai chi) in patients with AIIA to guide the development of formal exercise prescription guidelines. Findings indicate that a mixed-modality regimen of aerobic and resistance exercises is feasible and safe and may serve the most benefit in improving joint pain, functionality, and quality of life. More specifically, the weekly regimen should consist of 150 min of aerobic exercise with two sessions of at least six resistance exercises, 8 to 12 repetitions, three sets each. Supplementary yoga and tai chi may be recommended twice a week depending on a patient's target symptoms. Yoga was associated with improved physical functionality, whereas tai chi was related to improvements in mental health. However, the feasibility and impact of combined aerobic and resistance exercise protocols with yoga or tai chi in our target population were not investigated in this review. The use of large, randomized controlled trials is recommended for future studies.

Chemotherapy-Induced Peripheral Neuropathy: Diagnosis, Agents, General Clinical Presentation, and Treatments.

PURPOSE OF REVIEW: This review aims to discuss pathophysiology, diagnosis, clinical presentation, and treatment of chemotherapy-induced peripheral neuropathy. Agent-specific presentation and pathophysiology is also being discussed. RECENT FINDINGS: As new systemic oncological treatments continue to be developed, the number of cancer survivors continues to grow. Survivors are living longer with the long-term side effects of oncological treatments. We reviewed the pathophysiology of agent-specific chemotherapy-induced peripheral neuropathy and the updates in its treatment and preventative tools. Chemotherapy-induced peripheral neuropathy is a debilitating long-term side effect that often impairs cancer survivors' function and quality of life. The increasing life expectancy of cancer survivors has resulted in increased prevalence of this condition. Understanding its intricacies can provide physicians with better treatment tools and research opportunities to develop or identify new therapeutic agents.

Predictors of cancer rehabilitation medicine referral and utilization based on the Moving Through Cancer physical activity screening assessment.

PURPOSE: Cancer survivors experience high rates of physical inactivity that often go unaddressed. The My Wellness Check program (MWC) is an EHR-integrated screening and referral system that includes surveillance of physical activity and triage to cancer rehabilitation medicine services. This study examined assessment of physical activity and subsequent referrals to cancer rehabilitation medicine. METHODS: A secondary analysis was performed for survivors who completed the MWC between April 2021 and January 2022. Univariable and multivariable logistic regression modeled determinants of qualification for a physical activity referral and provider completion of referral to cancer rehabilitation medicine. Referral was based on responses to the Moving Through Cancer questionnaire. Adjusted odds ratios (aOR) and corresponding 95% confidence intervals (95% CI) were calculated. RESULTS: There were 1,174 survivors who completed the assessment, of which 46% (n = 540) reported physical inactivity. After controlling for group differences, individuals with moderate-severe physical dysfunction (aOR: 1.750; 95% CI: 1.137, 2.693) had higher odds, and self-reporting Hispanic or Latino ethnicity (aOR: 0.720; CI: 0.556, 0.932) had lower odds of physical inactivity. Only 31% (n = 168) received a completed physician referral to cancer rehabilitation medicine following identification of physical inactivity. No patient-level factors were associated with receiving a physician referral. Following referral, 8% (n = 13) utilized cancer rehabilitation medicine services. CONCLUSIONS: Patient-level and clinical factors may predict qualification for physical activity referrals; however, they don't appear to predict referral completion to cancer rehabilitation medicine. Future research should focus on potential provider- and organization-level factors that interact and influence access to cancer rehabilitation medicine services.

Knowledge, attitudes, and beliefs of oncology trainees on function and cancer rehabilitation medicine.

BACKGROUND: Improved function is associated with reduced morbidity and mortality in patients with cancer. Cancer rehabilitation medicine (CRM) is a subspecialty of physical medicine and rehabilitation (PM&R) that focuses on improving function in patients with cancer. One of the barriers to patients accessing CRM services is the lack of referrals from oncology providers. Understanding the knowledge, attitudes and beliefs of oncology trainees regarding the importance of function and the role of CRM is essential to reducing educational gaps and improving patients' access to essential rehabilitation services. OBJECTIVE: To determine oncology trainees' knowledge, attitude and beliefs about the importance of function and the role of CRM in the care of patients with cancer. SETTING: The study was conducted at a comprehensive cancer center in the United States. INTERVENTION: Descriptive survey study was administered to postgraduate oncology trainees who spent at least 1 day a week providing patient care. MAIN OUTCOME: Participants' report of their knowledge, attitudes, and beliefs on the importance of function and CRM in the care of patients with cancer. RESULTS: The survey was sent to 197 oncology trainees with a response rate of 67% (n = 132) and 126 were ultimately included. All participants believed that function is important in the care of patients with cancer. The majority believed that better function improves treatment tolerance (94%) and survival (84%). Most reported that having CRM physicians (80%) and an inpatient rehabilitation unit (88%) in the oncological setting is important; however, most participants reported that they refer fewer than 25% of their patients to CRM services. Participants with prior exposure to PM&R were significantly more likely to consult PM&R compared to those without exposure (p = .005). Most oncology trainees (81%) believed that education in CRM should be part of their oncology training. CONCLUSION: This study demonstrates that oncology trainees believe that function is important. They also believe that access to CRM would improve treatment tolerance and survival, but most report that they rarely refer patients to CRM services. Most trainees desire increased exposure to CRM during oncology training.

Nontraumatic Spinal Cord Injury: Epidemiology, Etiology and Management.

The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a traumatic spinal cord injury (SCI), supraspinal influences on the peripheral nervous system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, sympathetic blunting, and parasympathetic dominance, resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions, and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of the less reported nontraumatic SCI (NTSCI), its classification, its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue. Finally, management strategies for NTSCI will be provided.

Virtually Possible: Medical Student Rehabilitation Rotations During a Pandemic.

ABSTRACT: The novel coronavirus 2019 pandemic has led to new dilemmas in medical education because of an initial shortage of personal protective equipment, uncertainty regarding disease transmission and treatments, travel restrictions, and social distancing guidelines. These new problems further compound the already existing problem of limited medical student exposure to the field of physical medicine and rehabilitation, particularly for students in medical schools lacking a department of physical medicine and rehabilitation, approximately 50% of medical schools. A virtual medical student physical medicine and rehabilitation rotation was created to mitigate coronavirus 2019-related limitations and impact on medical education. Using audiovisual technology, students had the opportunity to participate in clinical inpatient and outpatient care, live-streamed procedures, and virtual didactics, develop and showcase their clinical knowledge and reasoning skills, and become familiar with the culture of the physical medicine and rehabilitation residency program. Adaptive educational approaches, including integration of the flipped classroom model, success, pitfalls, and areas for improvement will be described and discussed. Providing nontraditional methods for physical medicine and rehabilitation education and exposure to medical students is crucial to maintain and promote growth of the field in this unprecedented and increasingly virtual era.

Functional Impairments and Rehabilitation Outcomes of Patients With Immunotherapy-Induced Acute Inflammatory Demyelinating Polyradiculoneuropathy, Myasthenia Gravis, and Myositis.

ABSTRACT: Immunotherapy has led to a higher survival rate among different oncological disease groups but also associated with adverse-related events in multiple organ systems. Immunotherapy-related musculoskeletal weakness often results in a loss of cancer survivors' physical function, ultimately impacting their independence and quality of life. This is a retrospective study of 24 cancer patients who were treated with immunotherapy either alone or in conjunction with other oncological treatments. Twelve subjects (50%) were found to have acute inflammatory demyelinating polyradiculopathy/Guillain-Barré syndrome, six (25%) myositis, two (8%) myasthenia gravis, two (8%) diagnosis of myositis/myasthenia gravis, and one (4%) Guillain-Barré syndrome/myasthenia gravis combination. Physical therapy was provided in 91.7% of the cases, and physiatrist was involved in 54% of the cases. Almost half (45%) were discharged home, six (25%) to acute inpatient rehabilitation, two (8%) to subacute rehabilitation, three (12.5%) to hospice, and two (8%) died. The average length of hospital stay was 30 days, and eight patients (33%) readmitted within 3 mos. Our findings highlight the severity of functional impairments and the need for early rehabilitation interventions.

Rehabilitation Utilization by Cancer Patients with Pathology-Confirmed Leptomeningeal Disease Receiving Intrathecal Chemotherapy.

ABSTRACT: The incidence of leptomeningeal disease (LMD) is believed to be increasing in part because of more effective chemotherapy treatments allowing cancer progression behind the blood-brain barrier. However, little has been published about the rehabilitation of this growing patient population. In this study, impairments and rehabilitation utilization by cytology-proven LMD patients receiving intrathecal chemotherapy at a cancer center are described. A total of 109 consecutive patients with pathology-confirmed LMD who received an intrathecal chemotherapy infusion from January 1, 2017, through October 31, 2017, were retrospectively reviewed. Of the 109 patients, 103 (95%) had impairments described in their medical record that could impact physical function, including 74 of 109 (68%) who had deconditioning or fatigue. Kaplan-Meier median survival from initial LMD diagnosis was 13.1 mos. The median number of hospital admissions and intrathecal chemotherapy administrations was both 8. Of the 109 patients, 43 (39%) had magnetic resonance imaging radiology interpreted LMD. Most LMD patients used rehabilitation services (95/109, 87%) and most were able to forego post-acute inpatient rehabilitation facilities (96/109, 88%). Additional research and education for rehabilitation professionals about this increasingly common syndrome are needed.

Immunotherapy-related skeletal muscle weakness in cancer patients: a case series.

Immunotherapy has become a lifeline in cancer treatment. However, increasingly reports of programmed death-1 (PD-1) inhibitors have been linked to autoimmune disorders. We highlight two unique cases that presented with skeletal weakness and resulted in fatalities after developing de novo myasthenia gravis and myositis associated to immunotherapy treatment. Additionally, we describe the importance of early symptoms recognition and prompt treatment in preventing prolonged functional impairments and decreasing associated mortality. Patient 1: a 65-year-old male with a history of metastatic clear cell Renal Cell Cancer with metastasis to the lungs presented with unusual neck weakness, double vision, trouble breathing, and symptoms of urinary incontinence after his 4th cycle of nivolumab (480 mg every 4 weeks). He had a positive fatigability test, diplopia, and proximal weakness in bilateral upper extremities with an abnormal negative inspiratory force (NIF). Patient 2: a 83-year-old male with history of metastatic urothelial carcinoma presented with generalized weakness, difficulty holding his head up and swallowing three days after receiving the second cycle of immunotherapy treatment with nivolumab (480 mg every 4 weeks). He had proximal muscle weakness but normal sensation, fatigability tests and reflexes, very abnormally high creatine kinase (CK) greater than 4,000 ng/L, EMG results of myopathy and muscle biopsy showing focal perimysial chronic inflammatory cell infiltrates. Patient 1 ultimately died due to acute hemorrhage while patient 2 had a prolonged hospitalization and rehabilitation and ultimately discharged home with hospice. Prompt symptom recognition and treatment can potentially prevent prolonged impairment and mortality associated with cancer immunotherapy.

Retrospective Analysis of Acute Rehabilitation Outcomes of Cancer Inpatients with Leptomeningeal Disease.

OBJECTIVE: Evaluate Functional Independence Measure (FIM) changes and incidence of serious medical complications requiring return to the primary acute care service of acute rehabilitation cancer inpatients with leptomeningeal disease (LMD). DESIGN: Retrospective chart review. SETTING: Tertiary referral based comprehensive cancer center acute inpatient rehabilitation unit. PARTICIPANTS: Thirty cancer patients admitted to acute inpatient rehabilitation between 8 January 2014 and 8 August 2018 with pathology confirmed LMD within 6 months. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM and incidence of return to the primary acute care service. RESULTS: Twenty five of 30 (83.3%) patients were noted to have neurologic impairments and 13/30 (43.3%) were noted to have cognitive impairments. Five of 30 patients (16.7%) received intrathecal chemotherapy and 4/30 (13.3%) received radiation during acute inpatient rehabilitation for LMD treatment. Median days in acute care prior to acute inpatient rehabilitation was 22.5. Median days from acute inpatient rehabilitation admission until death of the 23 deceased patients as of 1 January 2019 was 180.00. Twenty of 30 (66.7%) patients were discharged home, 9/30 (30%) transferred to the primary acute care service, and 1/30 (3.3%) discharged to a skilled nursing facility. Reasons for return to the primary acute care service included additional chemotherapy 3/9 (33%), neurologic decline 2/9 (22%), fever 2/9 (22%), altered mental status 1/9 (11%), and progressive polyarthritis 1/9 (11%). Of the 21 patients who completed acute inpatient rehabilitation without return to the primary acute care service, mean FIM subscore changes from admission to discharge for Activities of Daily Living, Mobility, and Motor were 5.1 (P < .001), 4.8 (P < .001) and 11.7 (P < .001), respectively (Wilcoxon signed rank test, significance P < .05). CONCLUSION: LMD patients who completed acute inpatient rehabilitation made statistically significant improvements on the majority of FIM items. Most patients were discharged home. Our data suggest LMD should not be a reason for exclusion from acute inpatient rehabilitation. LEVEL OF EVIDENCE: III.

Disparities in Health Care for Hispanic Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review.

In the United States, the number of people with Hispanic backgrounds is rapidly increasing. This growth, along with other factors, may put them at increased risk for healthcare disparities. Thus, physical medicine and rehabilitation should evaluate disparities in health services through the lens of the evidence base. To our knowledge, this is the first review describing the literature on healthcare disparities for Hispanic patients in the field of physical medicine and rehabilitation. This review explores healthcare utilization, risk factors, access, and health conditions specific to Hispanic populations. Articles used in this narrative review were collected for a 10-yr span (2009-2018) from online databases.Our findings highlight disparities across common conditions and injuries in the physical medicine and rehabilitation literature, including poststroke rehabilitation, hip fracture treatment and rehabilitation, spinal cord injury, and traumatic brain injury. Our review suggests that Hispanic patients may be at risk for worse outcomes after these conditions, because of low access to rehabilitation services and disparities in the referral process. Similar results are reported for pain management and Parkinson disease. As we strive to provide optimal care to an increasingly diverse patient population, researchers and clinicians must consider effects of race and ethnicity on access to and utilization of rehabilitation services.

Perfil de salud mental en víctimas del desplazamiento forzado con síntomas de TEPT en Barranquilla, Colombia / Mental health profile in victims of forced displacement with symptoms of PTSD in Barranquilla, Colombia

Se describe el perfil de salud mental en víctimas del desplazamiento forzado con síntomas de TEPT de la urbanización Villas de San Pablo, en Barranquilla (Colombia). La investigación se realizó a partir de exploraciones en entrevistas a profundidad, taller investigativo, y un registro observacional con indicadores, creados a partir de las dimensiones del bienestar psicológico de Ryff, subjetivo de Diener, social de Keyes, y estrategias de afrontamiento de la Escala de Estrategias de Coping ­ Modificada (EEC-M). Las categorías derivadas del análisis de contenido permitieron identificar los recursos psicosociales con los que cuentan los individuos. Estos recursos fueron englobados en factores protectores y de riesgo, evidenciando estilos de afrontamiento activos y evitativos/pasivos que revelaron un perfil de salud mental semejante a los descritos en la literatura sobre víctimas de violencia socio-política. Se incita a crear programas que aporten a la salud mental de los individuos mediante la promoción de factores protectores.

Mental health profile will be described in victims of forced displacement with PTSD symptoms from Villas de San Pablo urbanization, in Barranquilla, Colombia. The study is based on the exploration carried out through an investigative workshop and in-depth interviews, as well as an observatory register by means of indicators, created from the Ryff´s psychological well-being dimensions, Diener´s subjective well-being, and Keyes's Social Well-Being, and coping strategies from the Coping Strategies Scale-Modified (EEC-M). The categories derived from the content analysis allowed to identify the psychosocial resources, classified as protective or risk factors, displaying actives and evitative/passives coping styles such as showing a mental health profile similar to the victims of socio-political violence literature. It is encouraged to create programs that contribute to the mental health of individuals through the promotion of protective factors.

Is the lateral jack-knife position responsible for cases of transient neurapraxia?

OBJECTIVE: The lateral jack-knife position is often used during transpsoas surgery to improve access to the spine. Postoperative neurological signs and symptoms are very common after such procedures, and the mechanism is not adequately understood. The objective of this study is to assess if the lateral jack-knife position alone can cause neurapraxia. This study compares neurological status at baseline and after positioning in the 25° right lateral jack-knife (RLJK) and the right lateral decubitus (RLD) position. METHODS: Fifty healthy volunteers, ages 21 to 35, were randomly assigned to one of 2 groups: Group A (RLD) and Group B (RLJK). Motor and sensory testing was performed prior to positioning. Subjects were placed in the RLD or RLJK position, according to group assignment, for 60 minutes. Motor testing was performed immediately after this 60-minute period and again 60 minutes thereafter. Sensory testing was performed immediately after the 60-minute period and every 15 minutes thereafter, for a total of 5 times. Motor testing was performed by a physical therapist who was blinded to group assignment. A follow-up call was made 7 days after the positioning sessions. RESULTS: Motor deficits were observed in the nondependent lower limb in 100% of the subjects in Group B, and no motor deficits were seen in Group A. Statistically significant differences (p < 0.05) were found between the 2 groups with respect to the performance on the 10-repetition maximum test immediately immediately and 60 minutes after positioning. Subjects in Group B had a 10%-70% (average 34.8%) decrease in knee extension strength and 20%-80% (average 43%) decrease in hip flexion strength in the nondependent limb. Sensory abnormalities were observed in the nondependent lower limb in 98% of the subjects in Group B. Thirty-six percent of the Group B subjects still exhibited sensory deficits after the 60-minute recovery period. No symptoms were reported by any subject during the follow-up calls 7 days after positioning. CONCLUSIONS: Twenty-five degrees of right lateral jack-knife positioning for 60 minutes results in neurapraxia of the nondependent lower extremity. Our results support the hypothesis that jack-knife positioning alone can cause postoperative neurological symptoms.

Retroperitoneal oblique corridor to the L2-S1 intervertebral discs: an MRI study.

OBJECT The purpose of this study was to analyze MR images of the lumbar spine and document: 1) the oblique corridor at each lumbar disc level between the psoas muscle and the great vessels, and 2) oblique access to the L5-S1 disc space. Access to the lumbar spine without disruption of the psoas muscle could translate into decreased frequency of postoperative neurological complications observed after a transpsoas approach. The authors investigated the retroperitoneal oblique corridor of L2-S1 as a means of surgical access to the intervertebral discs. This oblique approach avoids the psoas muscle and is a safe and potentially superior alternative to the lateral transpsoas approach used by many surgeons. METHODS One hundred thirty-three MRI studies performed between May 4, 2012, and February 27, 2013, were randomly selected from the authors' database. Thirty-three MR images were excluded due to technical issues or altered lumbar anatomy due to previous spine surgery. The oblique corridor was defined as the distance between the left lateral border of the aorta (or iliac artery) and the anterior medial border of the psoas. The L5-S1 oblique corridor was defined transversely from the midsagittal line of the inferior endplate of L-5 to the medial border of the left common iliac vessel (axial view) and vertically to the first vascular structure that crossed midline (sagittal view). RESULTS The oblique corridor measurements to the L2-5 discs have the following mean distances: L2-3 = 16.04 mm, L3-4 = 14.21 mm, and L4-5 = 10.28 mm. The L5-S1 corridor mean distance was 10 mm between midline and left common iliac vessel, and 10.13 mm from the first midline vessel to the inferior endplate of L-5. The bifurcation of the aorta and confluence of the vena cava were also analyzed in this study. The aortic bifurcation was found at the L-3 vertebral body in 2% of the MR images, at the L3-4 disc in 5%, at the L-4 vertebral body in 43%, at the L4-5 disc in 11%, and at the L-5 vertebral body in 9%. The confluence of the iliac veins was found at lower levels: 45% at the L-4 level, 19.39% at the L4-5 intervertebral disc, and 34% at the L-5 vertebral body. CONCLUSIONS An oblique corridor of access to the L2-5 discs was found in 90% of the MR images (99% access to L2-3, 100% access to L3-4, and 91% access to L4-5). Access to the L5-S1 disc was also established in 69% of the MR images analyzed. The lower the confluence of iliac veins, the less probable it was that access to the L5-S1 intervertebral disc space was observed. These findings support the use of lumbar MRI as a tool to predetermine the presence of an oblique corridor for access to the L2-S1 intervertebral disc spaces prior to lumbar spine surgery.

Can triggered electromyography be used to evaluate pedicle screw placement in hydroxyapatite-coated screws: an electrical examination.

OBJECTIVES: To assess if hydroxyapatite (HA)-coated titanium pedicle screws exhibit the same electroconductive characteristics as non-HA-coated screws. METHODS: Resistance measurements were obtained from a random sampling of 10 HA-coated pedicle screws and 10 non-HA-coated screws, and surgical conditions simulated. Surface resistivity measurements were taken for each screw to determine voltage drop over its entire length. RESULTS: The non-HA-coated screws tested showed low resistive properties and proved to be an ideal conductor of electrical current. The resistive properties associated with the HA-coated pedicle screws were found to be similar to those of commonly used insulators removing the effectiveness of triggered electromyographic responses. CONCLUSIONS: Based on test results, these data suggest that the resistance value of the HA-coated screw is large enough to prevent modern Intra-Operative Monitoring (IOM) equipment from delivering the necessary current through the shank of the screw to create a diagnostic electromyographic response. Any response that would be produced would be because of shunting of electric current from the non-coated head of the screw into adjacent tissue and not through the shank of the screw. These study results suggest that HA-coated screws cannot be stimulated to assist in determining the accuracy of pedicle screw placement.